Persons using assistive technology might not be able to fully access information in this file. For assistance, please send e-mail to: mmwrq@cdc.gov. Type 508 Accommodation and the title of the report in the subject line of e-mail.

Brief Report: Lead Poisoning from Ingestion of a Toy Necklace ---
Oregon, 2003

Although ingestion of dust from lead-based paint is the most common source of lead exposure among children in
the United States (1), lead also can be present in unsuspected objects. Ingestion of these objects can result in elevated blood
lead levels (BLLs). This report describes an investigation by the Deschutes County Health Department and the
Oregon Department of Human Services of lead poisoning in a boy who swallowed a medallion pendant from a neckace sold in a
toy vending machine. The investigation resulted in a nationwide recall in September
2003of the implicated toy necklace. Clinicians and caregivers should consider lead poisoning in any child who ingests, or puts in his mouth, a metal object. Cases of lead poisoning should be reported immediately to public health authorities to prevent other children from being exposed
to the same sources of lead.

In July 2003, a boy aged 4 years was taken to a physician in Oregon after several days of abdominal cramping,
vomiting, and diarrhea without fever. His symptoms resolved until 1--2 weeks later when he had another bout of vomiting
and abdominal pain. He was returned to his physician, and his condition was diagnosed as probable viral syndrome and anemia of undetermined etiology.

Two days later he was brought to the emergency department with worsening symptoms, including constipation and
inability to eat or sleep because of his abdominal pain. An abdominal radiograph showed a metallic object in the stomach with no evidence of obstruction; repeat laboratory studies showed a persistent normocytic anemia. Initially, the object was believed likely to pass on its own; however, on the next day, an abdominal computerized tomography showed the object
more superiorly located. Endoscopy was performed, resulting in retrieval of a medallion pendant (along with a quarter) from
the boy's stomach.

Three days later, the boy returned with edema of the left cheek and gingiva, suggesting either a dental abscess or
excessive biting of the cheek. Concern that the cheek bite might have been caused by a seizure prompted testing of his BLL, which was 123 µg/dL (CDC's level of concern =
>10 µg/dL). The boy was admitted to the pediatric intensive care unit for
intravenous chelation therapy. No evidence of encephalopathy was found; a sleep electroencephalogram was normal. The boy was treated with dimercaprol (i.e., BAL) followed by calcium disodium versenate (i.e., EDTA), and his BLL decreased to 57 µg/dL. He was switched to oral succimer (i.e., DMSA), but received a repeat course of EDTA when his BLL increased to 69 µg/dL. After three courses of succimer, his BLL was <40
µg/dL. The boy's zinc protoporphyrin level peaked at 556
mM/M (normal: 25--65 mM/M). Peripheral blood smear showed basophilic stippling. Subsequently, neurodevelopmental, cognitive, and speech therapy evaluations of the boy all showed appropriate development.

An environmental investigation of the boy's home, which was built in 1996, did not reveal any additional sources of
lead exposure. A sibling, aged 6 years, had a BLL of <5
µg/dL.

The medallion retrieved from the boy's stomach was reportedly purchased from a toy vending machine in
Oregon, approximately 3 weeks before it was retrieved. The state environmental quality lab found the medallion's contents to be 38.8% lead (388,000 mg/kg), 3.6% antimony, and 0.5% tin. Similar medallions purchased from toy vending machines in other areas of Oregon were found to have similar high proportions of lead (44% and 37%). These medallions are round,
measuring approximately 7/8 of an inch in diameter, gray in color, with a symbol on one side (Figure).
State health officials notified the U.S. Consumer Product Safety Commission; a national voluntary recall* was announced on September 10, 2003, of approximately 1.4 million of the metal toy
necklaces. A distributor of the medallions reported that they had been
manufactured in India and distributed throughout the United States. Oregon health officials cautioned that more of the medallions might
still be sold in vending machines in the state
(2).

Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of
Health and Human Services.References to non-CDC sites on the Internet are
provided as a service to MMWR readers and do not constitute or imply
endorsement of these organizations or their programs by CDC or the U.S.
Department of Health and Human Services. CDC is not responsible for the content
of pages found at these sites. URL addresses listed in MMWR were current as of
the date of publication.

DisclaimerAll MMWR HTML versions of articles are electronic conversions from ASCII text
into HTML. This conversion may have resulted in character translation or format errors in the HTML version.
Users should not rely on this HTML document, but are referred to the electronic PDF version and/or
the original MMWR paper copy for the official text, figures, and tables.
An original paper copy of this issue can be obtained from the Superintendent of Documents,
U.S. Government Printing Office (GPO), Washington, DC 20402-9371; telephone: (202) 512-1800.
Contact GPO for current prices.

**Questions or messages regarding errors in formatting should be addressed to
mmwrq@cdc.gov.